The purpose of this application is to develop, implement, and evaluate an implicit review method for measuring the quality of nursing care delivered to acutely ill, hospitalized Medicare patients. Implicit review of medical records describes the assessment of quality of care based on a health care professional's own judgement. Relatively little scientific research has focused specifically on determining the quality of nursing care through implicit review of nursing notes, nor on the relationships between nursing care, physician care, appropriate use of service, and patient outcomes. The specific aims of this project are to: 1. Review the nursing literature regarding nursing notes and quality of care. 2. Convene a panel of nurses to help design structured implicit review forms that reflect nursing priorities and that separately identify nursing quality, short term nursing outcomes, nurse-rated physician quality, and the quality of other hospital services. 3. Measure the quality of nursing care received by a nationally representative sample of patients hospitalized with congestive heart failure and cerebrovascular accident, using the nurse structured implicit review form (applied by nurse reviewers) and an existing nationally representative sample of medical records. 4. Assess the reliability and validity of the nurse structured implicit review form and evaluate the link between the quality of the process of care and the outcomes of care including reduction in symptoms, 30 and 180 day death, and hospital readmissions. 5. Assess the variations in types of nursing notes and in nursing quality of care across geographic regions, types of hospitals, and time period. 6. Analyze discrepancies between different reviews of the same medical records. This study will provide an important methodological step towards improved understanding of the nursing process and its influence on patient outcomes.